SummaryTreating complex aortic arch disease with proximal and distal aortic segment involvement is challenging. In recent years, different surgical and endovascular techniques have been applied in a single or multiple-stage approach with the aim to cure and simplify these conditions. The first procedure available for this purpose was the conventional elephant trunk technique. Its recent evolution is the frozen elephant trunk, which treats the descending thoracic aorta using the antegrade release of a self-expandable stent graft. In the following review article, we analyse the advantages and drawbacks of both techniques from clinical and practical perspectives.

The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.

Type B aortic dissection can be treated effectively with TEVAR. The incidence of distal SINE is not negligible but is not associated with poor outcomes. The main determinant of SINE seems to be an excessive oversizing, which is particularly evident in the distal end. More accurate sizing can be obtained by evaluating the area of the true lumen.

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EVAR leads to changes in coagulation and fibrinolysis, with characteristic developments. These latter have no clinical relevance and have no effect on early outcome and on mid-term follow-up.